Abstract Objective The study aimed to assess in a prospective randomized study the effect of Mozart's music on time to regain birth weight (BW) and development of oral feeding skills in babies born between 280/7 and 316/7 weeks of gestation. Study Design Healthy premature infants born between 280/7 and 316/7 completed weeks of gestation were randomized within 3 days of birth to either music or no music exposure. Infants in the music group were exposed to Mozart's double piano sonata twice per day for 14 days. The primary outcome was time to regain birth weight. The secondary outcome was development of oral feeding skills as evaluated by a speech/language pathologist blinded to the intervention. We hypothesized that exposure to Mozart's double piano sonata would decrease time to regain BW and improve feeding skills. A total of 32 newborns were needed to detect a 3-day difference in time to regain BW. Results Forty infants were enrolled and randomized. There were no significant differences between the two groups regarding the time to regain BW (p = 0.181) and the time to achievement of full oral feeds (p = 0.809). Conclusion Exposure to Mozart's double piano sonata for 14 days after birth did not significantly improve time to regain BW or time to achieve full oral feedings in very premature infants. It is possible that Mozart's music has no effect or that the duration of music exposure was not sufficient to have a physiologic effect on growth and oral feeding skills. Key Points Classical music improves the medical condition of adults. Music decreases neonatal resting energy expenditure. Music exposure did not significantly impact weight gain. This clinical relevance warrants further evaluation.

Policy Points State-level social and economic policies that expand tax credits, increase paid parental leave, raise the minimum wage, and increase tobacco taxes have been demonstrated to reduce adverse perinatal and infant health outcomes. These findings can help prioritize evidence-based legislated policies to improve perinatal and infant outcomes in the United States. Context Rates of preterm birth and infant mortality are alarmingly high in the United States. Legislated efforts may directly or indirectly reduce adverse perinatal and infant outcomes through the enactment of certain economic and social policies. Methods We conducted a narrative review to summarize the associations between perinatal and infant outcomes and four state-level US policies. We then used a latent profile analysis to create a social and economic policy profile for each state based on the observed policy indicators. Findings Of 27 articles identified, nine focused on tax credits, eight on paid parental leave, four on minimum wages, and six on tobacco taxes. In all but three studies, these policies were associated with improved perinatal or infant outcomes. Thirty-three states had tax credit laws, most commonly the earned income tax credit (n = 28, 56%). Eighteen states had parental leave laws. Two states had minimum wage laws lower than the federal minimum; 14 were equal to the federal minimum; 29 were above the federal minimum; and 5 did not have a state law. The average state tobacco tax was $1.76 (standard deviation = $1.08). The latent profile analysis revealed three policy profiles, with the most expansive policies in Western and Northeastern US states, and the least expansive policies in the US South. Conclusions State-level social and economic policies have the potential to reduce adverse perinatal and infant health outcomes in the United States. Those states with the least expansive policies should therefore consider enacting these evidence-based policies, as they have shown a demonstratable benefit in other states.

Objective This study aimed to determine if formula selection, low lactose versus standard term formula, has an effect on outcomes with a comparison to breastfed infants. Study Design Retrospective cohort study of neonates >= 35 weeks gestation born with Neonatal Abstinence Syndrome (NAS) was conducted from July 2014 to November 2016. Primary outcomes included length of pharmacologic treatment (LOT), and length of stay (LOS), and weight change per day comparing term standard and low lactose formula majority feeding infants with secondary outcomes comparing breast fed majority feeding infants. Results After investigating feeding methods for 249 NAS infants, a direct comparison of formula groups showed no differences in LOS (3, 95% confidence interval [CI]: -1.1 to 7 days), LOT (3.9, 95% CI: -0.4 to 8.1 days), or weight change per day (-2.4, 95% CI: -11.7 to 6.9 g/day). Breastfeeding improved LOT by 6.9 (95% CI: 3.4-10.5) and 10.8 days (95% CI: 5.9-15.6) and LOS by 7.4 (95% CI: 4.1-10.7) and 10.3 (95% CI: 5.8-14.9) days all reaching significance, in comparison to term and low lactose formula groups, respectively. Weight change per day was greater in the breast versus formula feeding groups when compared individually. Conclusion We detected no benefit to low lactose formula in NAS infants. Breastfeeding is associated with clinical reduction in LOS and LOT but is associated with increased weight loss.

Objective To assess the feasibility of real-time monitoring of work of breathing (WOB) indices and the impact of adjusting HFNC flow on breathing synchrony and oxygen stability in premature infants. Study design A prospective, observational study of infants stable on HFNC. The flow adjusted per predetermined algorithm. Respiratory inductive plethysmography (RIP) noninvasively measured WOB. A high-resolution pulse oximeter collected oxygen saturation and heart rate data. Summary statistics and mixed linear models were used. Results Baseline data for 32 infants, final analysis of 21 infants. Eighty-one percent with abnormal WOB. Sixty-two percent demonstrated 20% improvement in WOB. For infants with gestational age <28 weeks, an incremental increase in HFNC flow rate decreased WOB ( p < 0.001) and improved oxygen saturation and stability ( p < 0.01). Conclusions Premature infants do not receive optimal support on HFNC. The use of a real-time feedback system to adjust HFNC is feasible and improves WOB, oxygen saturation, and oxygen stability. This technology may improve the utility of HFNC in premature infants.

We experimentally investigate buyer and seller behavior in small markets with two kinds of frictions. First, a subset of buyers may have (severely) limited information about prices, and choose a seller at random. Second, sellers may not be able to serve all potential customers. Such capacity constraints can lead to coordination frictions where some sellers and buyers may not be able to trade. Theory predicts very different equilibrium outcomes when we vary the set-up along these two dimensions. In particular, it implies that a higher number of informed buyers will lead to lower prices when sellers do not face capacity constraints, while prices may actually increase if sellers are capacity constrained, as shown by Lester (2011). In the experiment, the differences between the constrained and non-constrained case are confirmed; prices fall when sellers are not capacity constrained but either do not fall by much or even increase when they are not. We find that prices are quite close to the predicted equilibrium values except in treatments where unconstrained sellers face a large fraction of informed buyers. However, introducing noise into the theoretical decision making process produces a pattern of deviations that fits well with the observed ones.

Objective Evaluate the effect of parental protective factors on parental stress at time of NICU admission and prior to discharge. Study design Parents of infants born at <35 weeks gestation were approached at a single level III NICU. Consenting parents completed a questionnaire on admission and prior to infant’s discharge of demographic information and three validated instruments: (1) parental stress (PSS:NICU), (2) Parents’ Assessment of Protective Factors (PAPF), and (3) health literacy (PHLAT-8). Results Mean PSS:NICU Total score was 2.8 ± 0.9 (Time 1) and 2.6 ± 1.1 (Time 2). Mean PAPF scores in all subcategories were high (means >3, ±0.3–0.5) (Time 1, Time 2). There was no clinically significant association between PSS:NICU scores and PAPF or any of the other measured variables. Conclusion PAPF and other commonly implicated factors were not associated with perceived self-reported parental stress at time of NICU admission and prior to discharge.

OBJECTIVE:The aim of the study is to determine length of stay and length of treatment in infants with neonatal abstinence syndrome (NAS) in the neonatal intensive care unit (NICU) compared to those in the pediatric floor. METHODS:Retrospective cohort of infants ≥34 weeks gestation admitted with diagnosis of NAS at a single regional perinatal referral center from July 2014 to October 2015. A standardized NAS protocol for both the NICU and pediatric floor, which included guidelines for the initiation of oral morphine, escalation, and weaning, was followed. Initial location of treatment, NICU or pediatric floor, was determined by physiological stability following birth. Statistical analysis included 1-way analysis of variance and chi-square. Multivariable analysis was performed using generalized linear models to account for confounding. RESULTS:The study included 235 infants, 80 (34%) were cared for in the NICU. Infants in the NICU had a longer length of stay (27.1 ± 19.1 vs 14.2 ± 10.2 days, P < 0.01), and length of pharmacological treatment (18.0 ± 19.9 vs 9.0 ± 10.2 days, P < 0.01) compared to those on the pediatric floor, respectively. Forty-seven infants were transferred from the NICU to the pediatric floor for the remainder of their hospital stay with a mean time on the pediatric floor of 17.4 ± 14.5 days. After controlling for confounding, admission to the NICU was associated with an increased length of treatment of 12.6 days (95% confidence interval 8.3-16.8) and length of stay of 12.3 days (95% confidence interval 7.9-16.6). CONCLUSIONS:In our population, admission to the pediatric floor compared to the NICU was associated with a shorter length of stay, and a shorter length of pharmacological treatment. Our data suggest that caring for infants with NAS outside of the NICU setting has the potential to improve short-term outcomes and reduce associated costs.

Strouss L, Goldstein ND, Locke R, Paul DA. Vascular placental pathology and the relationship between hypertensive disorders of pregnancy and neonatal outcomes in very low birth weight infants. J Perinatol. In Press.

The study aim was to identify the frequency with which tidal volumes were achieved in a target range in infants requiring positive pressure ventilation on emergency transport. We performed a prospective observational study of infants requiring continued positive pressure ventilation during emergency transport after resuscitation and stabilization. Blindly recorded data were analyzed for percentage of breaths that were below range, in range, and above desired range of 4–6 mL/kg. Fourteen patients were monitored during transport from the delivery room to the neonatal intensive care unit, and 15 patients were monitored during inter-facility transport. During delivery room transport, 21 and 7% of patients were in target range greater than 50 and 90% of the time, respectively. During inter-hospital transport, 60 and 7% of patients were in target range greater than 50 and 90% of the time, respectively. Clinical assessment of appropriate ventilation is difficult and often inaccurate during emergency neonatal transport. Improved monitoring of respiratory function to guide clinical status during transport is necessary. More investigation and implementation are urgently needed.

BACKGROUND While there is a general agreement that physicians are not obligated to provide futile care, there is a vigorous debate and little agreement on the definition of futile care, especially as applied to the neonatal population. Previous studies in adult medicine have demonstrated differences of opinions regarding the definition of futility between healthcare providers at different levels of training, but to our knowledge, no such study exists for the neonatal population. OBJECTIVES The primary objective is to assess if differences exist amongst neonatal healthcare professionals …

Delaware’s infant mortality rate remains above Healthy People 2020 targeted goal of 6.0 per 1000 births (Figure 1).1,2 The structural issues that underline the Delaware’s elevated rate require a forward-thinking public health approach. This commentary and review will describe the underlying factors contributing to Delaware’s infant mortality rate (IMR), and the Delaware State Governmental, State Health Systems and public health entities current approaches and challenges to improve outcomes.

Endotracheal tube (ETT) obstruction from biofilm formation is a theoretical risk for intubated preterm neonates. The objective of this study is to determine the impact of ETT biofilm on ETT resistance and minute ventilation in a neonatal respiratory model. Postextubation 2.5- and 3.0-mm ETTs from ventilated preterm infants were matched with unused control ETTs. The pressure gradient across the ETT was measured at set flow rates and converted to airway resistance. Spontaneous breathing tests (SBTs) were performed using a virtual patient model and were considered “passed” if minute ventilation of patient ETTs was greater than 60% of control ETTs. Twenty-four 2.5-mm ETTs and sixteen 3.0-mm ETTs were analyzed. In both patient and control ETTs, as flow rate increases, the pressure gradient across the ETT also increases in a linear fashion. Resistance to flow in patient ETTs was statistically different from matched control ETTs ( P < 0.001), and patient ETTs had 19.9 cmH2O·l−1·sec−1 greater resistance than control ETTs. SBTs were performed in 27 of 40 ETTs. Twenty-six ETTs “passed” an SBT. In one obstructed 3.0-mm ETT, SBT measurements were unobtainable. The clinical impact of ETT biofilm as measured by a SBT appears to be minimal for the majority of patients in our study group. In 1 out of 27 ETTs, the presence of a biofilm significantly altered resistance to airflow and resulted in a failed SBT. Gas flow rate and ETT size had a greater impact on resistance to airflow and minute ventilation than ETT biofilm in this study sample. NEW & NOTEWORTHY This is the first study to our knowledge to characterize the impact of endotracheal tube (ETT) biofilm and respiratory secretions on resistance to airflow in a neonatal ETT using a simulation neonatal lung model. Results show that the clinical impact of ETT biofilm is minimal for the majority of patients in our study group, and ETT obstruction from biofilm is an uncommon cause of respiratory decompensation in a preterm neonate.

Antenatal corticosteroids are standard of care for women at risk of a preterm birth and demonstrated to be protective against poor outcomes in neonates including respiratory disorders, mortality and intraventricular hemorrhage (IVH). Its benefits may vary by gestational age, and accurate estimation is needed in a single-center population to account for practice variation.

Background: There are limited data on parental perception of infant participation in minimal risk and minor increase above minimal risk research focusing on the NICU population. The study objective was to assess parental and NICU staff perceptions concerning minimal risk and minor increase above minimal risk in the NICU setting.Methods: Parents of infants and NICU staff were presented with a combination of 4 infant scenarios and 5 hypothetical research procedures. These assessed participants' willingness to allow their infant to participate in research and their attitude towards obligation to assist future children. Linear and hierarchal linear models analyzed the association and interaction effects on the likelihood to consent to research procedures.Results: Sixty parents and 30 NICU staff members were surveyed. Parents' acceptability for each of the five research procedures ranged from 31 % to 83 %. Parent gender, age, race/ethnicity, insurance, education and history of previous child in the NICU were not associated with the likelihood to consent to the research procedures. Acceptability for each of the five research procedures among NICU staff ranged from 19 % to 98 %. There were no significant differences between NICU staff's and parents' responses for 4 of 5 research procedures. A minority of parents and nurses (38.3 % and 40 % respectively), compared to a majority of physicians (66.7 %), agreed or strongly agreed that parents have a responsibility to involve their children in low risk medical research in order to help future children, even if this would not help their own child. Lower agreement with obligation to help future children (p < 0.01) and higher education (p = 0.01) were associated with a decreased likelihood to consent to research procedures.Conclusion: In our study population, common NICU-related research procedures were considered appropriate and acceptable to a diverse group of NICU parents representing a wide range of race/ethnic and socioeconomic strata. Current regulations guiding informed consent for minimal and minor increase over minimal risk research in the NICU environment appear ethically consistent with a diverse group of parents and providers.

Background:Health Literacy is the ability to obtain, process, and understand health information to make knowledgeable health decisions. Purpose:To determine baseline health literacy of neonatal intensive care unit (NICU) parents at a tertiary care hospital during periods of crucial information exchange. Methods:Health literacy of English-speaking NICU parents was assessed using the Newest Vital Sign (NVS) on admission (n = 121) and discharge (n = 59). A quasi-control group of well-baby nursery (WBN) parents (n = 24) and prenatal obstetric clinic (PRE) parents (n = 18) were included. A single, Likert-style question measured nurses' assessment of parental comprehension with discharge teaching. Suspected limited health literacy (SLHL) was defined as the NVS score of 3 or less. Findings/Results:Forty-three percent of parents on NICU admission and 32% at NICU discharge had SLHL (P < .01). SLHL for WBN and PRE parents was 25% and 58%, respectively. Parental age, gender, location, and history of healthcare-related employment were not associated with health literacy status at any time point. Thirty-nine percent of NICU parents and 25% of WBN parents with SLHL at time of admission/infant birth had a college education. Nurse subjective measurement of parental comprehension of discharge instructions was not correlated to the objective measurement of health literacy (P = .26). Implications for Practice:SLHL is common during peak time periods of complex health discussion in the NICU, WBN, and PRE settings. NICU providers may not accurately gauge parents' literacy status. Implications for Research:Methods for improving health communication are needed. Studies should evaluate SLHL in a larger NICU population and across different languages and cultures.

OBJECTIVES:Admission to the NICU is influenced by physiologic compromise and by hospital care protocols. Providing appropriate care must be balanced with adverse consequences of NICU admission, such as interrupting maternal-infant bonding and unnecessary interventions. This study aims to determine the variation in NICU admissions in term and late preterm infants among 19 hospitals.METHODS:We used the Consortium on Safe Labor (CSL) database to determine NICU admission rates. This database includes data from 217 442 infants aged 35 to 42 weeks within 19 US maternal delivery hospitals from 2002 to 2008. NICU admission rates were evaluated for absolute factors including, but not limited to, sepsis, asphyxia, respiratory distress, and intracranial hemorrhage, as well as relative factors, such as maternal drug use, chorioamnionitis, and infant birth weight ≤ 2500 g.RESULTS:Percentage of infants 35 to 42 weeks' gestation admitted to the NICU without an identifiable absolute or relative cause for intensive care services ranged from 0% to 59.4% (mean, 10.8%; P < .001). Among infants 35 to 42 weeks' gestation and ≥ 2500 g, infants without absolute or relative identified cause accounted for 9.1% of total NICU days and had lower length of stays (-2.7 days; 95% confidence interval -3.4; -2.1) compared to those with an identified reason.CONCLUSIONS:There is significant variation in admission rates among NICUs that cannot be explained by infant health conditions. Further analysis is needed to determine the cause of between-site variation and potential opportunities to refine protocols and optimize use of NICU services.

BACKGROUND:The prevalence of ventricular septal defects (VSDs), a birth defect in which there is an opening in the wall that separates the left and right ventricles of the heart, seemed to be substantially higher in Delaware compared with the National Birth Defects Prevention Network (NBDPN). The Delaware Birth Defects Registry (BDR) noted their high prevalence of VSDs in comparison with other states.METHODS:A subset of children with a VSD born in 2007 through 2010 was identified from the complete reportable statewide defect list that the BDR creates each year. VSDs were categorized by type of VSD (muscular, perimembranous, conotruncal, or atrioventricular septal defect), by either isolated or complex, and then by spontaneously closed, surgically closed, open but clinically insignificant, lost to follow-up, fetal or neonatal death.RESULTS:The BDR team found a prevalence of VSD of 83.4 per 10,000 including fetal/neonatal deaths. Excluding fetal and neonatal deaths the prevalence was 78.7 per 10,000 live births. Excluding small muscular VSDs, the prevalence in Delaware falls to 25.7 per 10,000.CONCLUSION:The BDR team chose to include all babies with all types of VSDs. Using these criteria Delaware's prevalence of 78.7 was higher than that reported by other states (whose prevalence ranges from 1.6 to 70.0 per 10,000 live births) (National Birth Defects Prevention Network, ). Delaware's prevalence is similar to other states when small muscular VSDs are excluded. Birth Defects Research (Part A) 106:888-893, 2016. © 2016 Wiley Periodicals, Inc.

BACKGROUND:Accurate prediction of future patient census in hospital units is essential for patient safety, health outcomes, and resource planning. Forecasting census in the Neonatal Intensive Care Unit (NICU) is particularly challenging due to limited ability to control the census and clinical trajectories. The fixed average census approach, using average census from previous year, is a forecasting alternative used in clinical practice, but has limitations due to census variations.OBJECTIVE:Our objectives are to: (i) analyze the daily NICU census at a single health care facility and develop census forecasting models, (ii) explore models with and without patient data characteristics obtained at the time of admission, and (iii) evaluate accuracy of the models compared with the fixed average census approach.METHODS:We used five years of retrospective daily NICU census data for model development (January 2008 - December 2012, N=1827 observations) and one year of data for validation (January - December 2013, N=365 observations). Best-fitting models of ARIMA and linear regression were applied to various 7-day prediction periods and compared using error statistics.RESULTS:The census showed a slightly increasing linear trend. Best fitting models included a non-seasonal model, ARIMA(1,0,0), seasonal ARIMA models, ARIMA(1,0,0)x(1,1,2)7 and ARIMA(2,1,4)x(1,1,2)14, as well as a seasonal linear regression model. Proposed forecasting models resulted on average in 36.49% improvement in forecasting accuracy compared with the fixed average census approach.CONCLUSIONS:Time series models provide higher prediction accuracy under different census conditions compared with the fixed average census approach. Presented methodology is easily applicable in clinical practice, can be generalized to other care settings, support short- and long-term census forecasting, and inform staff resource planning.

ObjectiveThe objective of the article is to determine if>48 hours of antibiotic treatment during the 1st week of life is associated with subsequent isolation of bacteria from the endotracheal tube (ETT), and an increased risk of bronchopulmonary dysplasia (BPD). Study DesignRetrospective cohort study of very low birth weight infants. Routine weekly surveillance ETT cultures were obtained to monitor bacterial colonization in all intubated infants. Risk factors for BPD were assessed using unadjusted and multivariable analyses. ResultsIn the study sample (n=906), infants with BPD (n=182) were more likely to have received>48 hours antibiotic treatment (31 vs. 14%, p<0.01) and have a resistant gram-negative bacilli in ETT (7 vs. 2%, p=0.0001) compared with infants without BPD. Treatment with>48 hours of antibiotics remained associated with BPD (adjusted odds ratio, 2.2; 95% confidence interval, 1.4-3.5) after controlling for confounding variables. ConclusionsAntibiotic duration>48 hours in the 1st week of life was associated with subsequent BPD and the presence of resistant bacteria in routine ETT cultures.

To study the association of advanced maternal age (AMA) and race/ethnicity on placental pathology in very low birthweight (VLBW) infants. Retrospective analysis of placental pathology of inborn singleton VLBW infants from a regional level 3 NICU between July, 2002 and June, 2009. Subjects were stratified by age and race/ethnicity. Statistical analysis included One-way ANOVA, Chi Square and multivariable analyses. A total of 739 mother/infant dyads were included. AMA was associated with a decrease in placental weight and placental weight/birthweight ratio. Black/Non-Hispanic mothers ≥35 had a lower placental weight (p = 0.01) and lower placental weight/birth weight ratio (z-score, −0.45 ± 0.71 vs −0.04 ± 1.1, p = 0.01) compared to Black/Non-Hispanic mothers <35 years of age. After controlling for gestational age, race/ethnicity, maternal diabetes, maternal smoking, maternal hypertension and clinical chorioamnionitis, AMA, but not race/ethnicity, remained independently associated with placental weight/birthweight ratio z score (full model r2 = 0.22, p < 0.01). In our study sample of VLBW infants, placental weight and placental weight/birthweight ratio were lower in mothers of advanced maternal age compared to mothers <35 years of age. Our data suggest that maternal age affects placentation in VLBW infants, which could influence maternal and neonatal outcomes.